Provider Demographics
NPI:1679048821
Name:ANDRE L COLEMAN
Entity Type:Organization
Organization Name:ANDRE L COLEMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYELANI
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-332-1475
Mailing Address - Street 1:8609 E 10TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2208
Mailing Address - Country:US
Mailing Address - Phone:907-332-1475
Mailing Address - Fax:
Practice Address - Street 1:8609 E 10TH AVE APT B
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-2208
Practice Address - Country:US
Practice Address - Phone:907-332-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility